During the shift change report, the nurse is told that a client has a stage 2 pressure injury. Which ulcer appearance is most likely to be observed?

An area of erythema that is painful to touch.

Shallow open ulcer with a red pink wound bed.

A deep pocket of infection and necrotic tissues.

Visible subcutaneous tissue with sloughing.

Answer and Explanation

The Correct Answer is B

A. A stage 2 pressure injury is more than just erythema; it involves partial-thickness skin loss.
B. A stage 2 pressure injury presents as a shallow open ulcer with a red or pink wound bed, indicating partial-thickness loss of dermis.
C. A deep pocket of infection and necrotic tissue describes a stage 3 or 4 pressure injury, not stage 2.
D. Visible subcutaneous tissue and sloughing are characteristics of stage 3 or 4 pressure injuries, not stage 2.

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Correct Answer is C

Explanation

A. Clamping the catheter before irrigation is not recommended as it could cause urine retention and increase the risk of infection.
B. An infusion pump is not typically used for catheter irrigation as manual control is preferred for monitoring flow and pressure.
C. Using a sterile syringe to gently irrigate the catheter with 20 mL of normal saline is the correct approach. This method helps to clear fibrin clots and sediment without applying excessive pressure, which could damage the bladder or catheter.
D. Power flushing with 60 mL could apply excessive pressure, potentially causing trauma to the bladder or urethra.

A. Recent oral intake. B. Difficulty with urination. C. Trouble sleeping. D. Unexplained weight loss.

Correct Answer is A

Explanation

A. Pyridostigmine is most effective when taken before meals to improve muscle strength for swallowing. Knowing the client's recent oral intake helps in timing the medication appropriately.
B. Difficulty with urination is not directly related to pyridostigmine use.
C. Trouble sleeping is not typically associated with pyridostigmine.
D. Unexplained weight loss may be related to myasthenia gravis but is not directly relevant to the immediate administration of pyridostigmine.

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During the shift change report, the nurse is told that a client has a stage 2 pressure injury. Which ulcer appearance is most likely to be observed?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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